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RESEARCH Open Access
A comparative evaluation of the process of
developing and implementing an emergency
department HIV testing program
Katerina A Christopoulos
1,2*
, Kim Koester
2
, Sheri Weiser
1,2
, Tim Lane
2
, Janet J Myers
2
and Stephen F Morin
2
Abstract
Background: The 2006 Centers for Disease Control and Prevention (CDC) HIV testing guidelines recommend
screening for HIV infection in all healthcare settings, including the emergency department (ED). In urban areas with
a high background prevalence of HIV, the ED has become an increasingly important site for identifying HIV
infection. However, this public health policy has been operationalized using different models. We sought to
describe the development and implementation of HIV testing programs in three EDs, assess factors shaping the
adoption and evolution of specific program elements, and identify barriers and facilitators to testing.
Methods: We performed a qualitative evaluation using in-depth interviews with fifteen ‘key informants’ involved in
the development and implementation of HIV testing in three urban EDs serving sizable racial/ethnic minority and
socioeconomically disadvantaged populations. Testing program HIV prevalence ranged from 0.4% to 3.0%.
Results: Three testing models were identified, refl ecting differences in the use of existing ED staff to offer and
perform the test and disclose results. Factors influencing the adoption of a particular model included: whether
program developers were ED providers, HIV providers, or both; whether programs took a targeted or non-targeted
approach to patient selection; and the extent to which linkage to care was viewed as the responsibility of the ED.
A common barrier was discomfort among ED providers about disclosing a positive HIV test result. Common

facilitators were a commitment to underserved populations, the perception that testing was an opportunity to re-
engage previously HIV-infected patients in care, and the support and resources offered by the medical setting for
HIV-infected patients.
Conclusions: ED HIV testing is occurring under a range of models that em erge from local realities and are tailored
to institutional strengths to optimize implementation and overcome provider barriers.
Background
The 2006 Centers for Disease Control and Prevention
(CDC) guidelines recommend routine HIV screening in
all healthcare settings where the HIV prevalence exceeds
0.1%, including the emergency department (ED) [1]. In
2007, the American College of Emergency Physicians
(ACEP) formally endorsed the mission of HIV testing in
EDs, provided that it did not interfere with the provision
of emergency care, was in compliance with state laws,
and was appropriately funded [2]. I n 2009, there were
over 20 CDC, public health department, National
Institutes of Health (NIH), and industry-funded ED HIV
testing programs at academic medical centers across th e
United States [3].
Though the CDC guidelines endorse non-targeted
screening and opt-out consent, ED HIV testing is cur-
rently occurring under a range of operational m odels,
with variation in patient selection strategies, methods of
consent, test c hoice, and use of support staff [4]. Les-
sons learned from implementing these models include
the importance of an ED testing ‘ champion,’ early buy-
in from key partners, quality control, protocols that
address education, disclosure, and linkage to care, feed-
back to ED clinicians, and mechanisms for funding and
sustainability [5,6]. To our knowledge, there has been

no qualitative study of the process of developing and
* Correspondence:
1
San Francisco General Hospital HIV/AIDS Division, University of California
San Francisco, San Francisco, CA, USA
Full list of author information is available at the end of the article
Christopoulos et al. Implementation Science 2011, 6:30
/>Implementation
Science
© 2011 Christopoulos et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attr ibution License (http://creativecommons. org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
implementing an ED HIV testing program. Qua litative
methods are useful for understanding the rationale for
programmatic choices in public policy implementation
and for identifying barriers to and facilitators of the
operationalization of p olicy guidel ines. As such, qualita-
tive research can contribute important knowledge to
health services evaluation.
In 2008, the CDC provided f unding to state and local
health departments to implement the 2006 guidelines and
increase the number of persons tested for HIV, particu-
larly in populations disproportionately affected by HIV,
such as African-Americans. Through this mechanism, the
California State Office of AIDS awarded grants to three
EDs in northern California to expand or initiate HIV test-
ing. The objectives of this study were to: characterize and
compare these ED HIV testing programs in terms of their
procedures; assess factors shaping the adoption and evolu-
tion of different testing models; and identify site-specific

and common barriers to and facilitators of HIV testing.
Methods
Study design
This study was a qualitative evaluation of the develop-
men t and implementa tion of three ED HIV testing pro-
grams using in-depth interviews with key program
personnel. The institut ional review boards of the Uni-
versity of California San Francisco and all participating
sites approved this study.
Setting
Of the three EDs, two belonged to county hospitals with
emergency medicine residency training programs and
one was part of a not-for-profit community health sys-
tem. The average annual number of patient visits at the
county EDs was between 60,000 and 75,000, while the
community hospital ED had a smaller census at 40,000.
All EDs were located in urban areas and served sizable
racial/ethnic minority and socioeconomically disadvan-
taged populations. According to internal data, the preva-
lence of HIV infection in these ED testing programs
ranged from 0.4% to 3.0%.
Selection of participants
Participation in this study was restricted to individuals
who were involved in the development or implementa-
tion of ED HIV testing. Recruitment began with meet-
ings of researchers and the principal investigators (PIs)
of the CDC grant at each site. At the meetings,
researc hers described the objectives of the study, invited
PI participation, and asked site PIs to identify and help
recruit key staff involved in the development and imple-

mentation of the ED testing programs. Researchers then
contacted participants and set up mutually convenient
times for interviews at each site.
Fifteen staff m embers (five from each program) took
part in the study, including ED and HIV clinic physi-
cians, ED and HIV clinic nurses, program coordinators,
and staff hired to administer HIV tests, who will be
referred to as dedicated testers. This purposeful sample
was recruited to understand the perspectives of program
developers and implementers at the three sites. These
fifteen staff members included all key personnel from
the implementation of each program.
Data collection and processing
Study data were collected from January to May 2009 by
four investigators with experience in qualitative
research. Researchers conducted in-depth interviews
with study partici pants that lasted 30 to 60 minutes and
were recorded and transcribed verbatim. Whenever pos-
sible, researchers interviewed participants in teams of
two. Each researcher conducted between three and
seven interviews. Researchers met to discuss their find-
ings on an ongoing basis.
A semi-structured interview guide was developed to
elucidate perspectives on the motivations and challenges
of providing HIV testing in the ED. The interview ques-
tions were situated within the broader context of federal
and state po licies designed to encourage HIV testing as
part of routine medical care. Specifically, the interview
guide covered five areas: the participant’sroleandlevel
of involvement in program development and implemen-

tation; a description of program procedures, with speci-
fic attention to the testing process elements outlined by
the National ED HIV Testing Consortium [7], including
patient selection, consent, testing metho ds, pre-result
communication, post-result communication, and o ut-
come measures, with an emphasis on linkage to care;
the program planning and implementation process;
facilitators and barriers to ED HIV testing, including
possible solutions to barriers; and the participant’ s
thoughts on whether screening for HIV should be the
same as for other chronic diseases, such as diabetes or
hypertension. Although the interviews covered each of
these five t opic areas whenever possible, they were also
iterative in nature, in that the interviewers followed up
on spontaneously offered information and raised issues
the y had learned about in previous interviews. Each site
received $250 for participating in the study.
Primary data analysis
Three members of the research team collaborated on
data analysis. A ll had been involved in data collection,
which contributed to an in-depth understanding of the
structure of ea ch program as well as of the roles of the
staff participating in th e research. These team members
represented different disciplines, i ncluding medicine/
health services research, medicine/anthropology, and
Christopoulos et al. Implementation Science 2011, 6:30
/>Page 2 of 9
anthropology/health services research. Framework analy-
sis was used to analyze the data. This type of analysis
originated in the context of applied social policy

research and its benefits include five transparent stages
of analysis that follow a well-defined process [8]. First,
the researchers familiarized themselves with the indivi-
dual interviews, noting key content areas (familiariza-
tion). Next, the researchers met as a group to identify
salient coding categories to be applied across interviews
(identifying a thematic framework). The cod ebook con-
sisted of both a priori codes derived from the evaluation
objectives to characterize and compare the HIV testing
models along with barriers and facilitators as well as
emergent codes. The research team applied the codes
and convened analysis retreat meetings to re ad and
summarize the data as a group (indexing). Together the
team created tables of the data associated with the
codes deemed most relevant (charting). The final phase
involved comparing and contrasting the models to
understand the similarities and differences of each case
(interpretation).
Results
ED HIV testing models
We identified three distinct ED HIV testing models. The
cent ral difference between the models was the extent to
which existing staff were used to carry out the activit ies
associated with HIV testing, including offering the test,
performing the test, and disclosing results. The first
model hired dedicated testers to accomplish HIV test-
ing. A second model relied fully on existing staff: physi-
cians offered the HIV test and the hospital laboratory
performed it. A third model combined elements of the
first two models, where triage nurses offered the HIV

test, dedicated testers conducted it, and physicians dis-
closed all results. For convenience, the first model will
be referred to as the parallel model, the second model
will be called the provider model, and the third model
will be known as the provider-parallel model. See Table
1 for a comparison of testing models.
All programs studied used rapid antibody testing.
However, the programs with parallel staff conducted
oral fluid swabs at the point of care, while the provider
model used the hospital laboratory to perform rapid
testing on b lood drawn by nurses. Point of care testing
gave results in 20 minutes while the hospital laboratory
reported r esults in the electronic medical record one to
two hours after specimen receipt. The hospital labora-
tory offered HIV testing around the clock, while the
parallel models had the staff capacity to test for most,
but not all, of a twenty-four hour period. Negative rapid
test results were considered HIV-negative results. Posi-
tive oral swabs were confirmed with blood drawn in the
ED, while positive rapid tests on the venipuncture
specimens used in the provider model were confirmed
using the same specimen.
Factors shaping the adoption and evolution of different
testing models
In comparing program implementation, w e found that
three related factors appeared to influence the adoption
of a particular testing model: whether programs took a
targeted or non-targeted approach towards patient selec-
tion for testing; whether program developers were ED
providers, HIV primary care providers, or both; and the

extent to which developers viewed linkage to care as a
primary responsibility of the ED test ing program rather
than that of HIV providers. Programs that took a non-
targeted approach to testing - i.e., the parallel and provi-
der-parallel models - relied on support staff to offer and
perform testing, while the pro vider model utilized a tar-
geted approach, choosing to incorporate testing into the
duties of existing staff. Programs where the HIV clinic
was actively i nvolved in development and implementa-
tion of the ED testing program had integrated linkage to
care mechanisms in which staff usually came to the ED
to meet patients with positive rapid test results.
Site one: The parallel model
The desire to provi der better patient care through diag-
nostic HIV testing initially motivated this ED to begin
an HIV testing program. As stated by one ED physician:
’It had nothing to do with HIV screening at all. I’man
emergency medicine physician and I like to make diag-
noses and I got frustrated because I would see patients
that I was convinced had an AIDS-defining illness or
clinical stigmata of AIDS and I couldn’t make a defini-
tive diagnosis in the emergency department.’
With the ability to perform diagnostic testing, the pro-
gram became more committed to screening, in part
because of the scope of available grants. This program
initially used existing staff (in this case, E D nurses) to
offer and perform non-targeted, point of care testing
and shifted to parallel staff only after some limitations
to using ED providers to screen patients became evi-
dent. One ED physician stated:

’It was always a str uggle getting them to routinely
offer and it was a struggle for a number of reasons.
Oneisthattheyhadahardtimefiguringoutwho
was eligible and who was ineligible. ‘This patient
looks a little too sick.’ They would definitely profile
who they would ask, so we didn’ t get true screening
by having the nurses do it. They would definitely
look at a little old lady and probably not offer it to
them.’
Christopoulos et al. Implementation Science 2011, 6:30
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Additional barriers were that nurses were busy, with
competing time demands, and some simply felt uncom-
fortable offering patients an HIV test. An important
logistical barrier was that patients who agreed to test
did not always complete the test because of a lack of
available staff to actually perform the test.
Having shown that HIV testing in the ED was feasi-
ble, program developers felt comfortable expanding
screening by hiring dedicated testers. The program
moved the offer of testing to ED registration, where
clerks asked patients to sign a box if they did not want
to be tested for HIV (opt-out screening). The primary
barrier identified under this organizational model was
the staffing challenge of maintaining quality control of
the point of care testing system according to laboratory
standards.
Though this program identified the hospital HIV clinic
as a key partner in initiating HIV testing, the HIV clinic
was not actively involved in the testing program, and

linkage to care in both phases of the program consisted
of referral by the ED to a guaranteed drop-in appoint-
ment at the clinic. As one ED physician described:
’Our job as the ED is to disclose, make sure the con-
firmatory testing gets done, and then give them fol-
low up in one of our clinics. And then the docs are
done and it becomes the responsibility of the clinic
to get them in ’
This view of link age to care was situated within a lar-
ger understanding of the role of the ED in triaging and
treating patients:
’Our goal is for patients to earn their preliminary
result, be able to answer questions, and get them to
the next step. That is kind of like the model of
emergency medicine physicianship: where does this
patient need to be, either I can fix it today or I need
to get them to the right hands ’
Site two: The provider model
In contrast to the screen ing and referral program at the
first site, the second site implemented a targeted testing
program with an integrated linkage component that
built upon existing systems in the hospital laboratory
and HIV clinic. Indeed, the ED was part of a larger hos-
pital-wide effort to change the hospital HIV testing plat-
form from batched enzyme immunoassay testing with
results available every two to three days to rapid anti-
body testing. Providers from the HIV clinic were actively
involved in creating the ED testing program and
Table 1 Characteristics of three emergency department HIV testing programs
Testing

Model
Testing
Program
Planners
Program
Already
Existed
at CDC
Grant
Award?
Rapid Test
Type
Patient
Selection
Criteria
Test Offer
and
Consent
Pre-test
Counselling
Test
Performer
Test Results
and
Confirmation
Disclosure Linkage to
Care
Parallel ED
clinicians
Yes Oral swab Non-

targeted
Signed
opt-out at
registration
At the
discretion of
the tester
Tester,
almost 24/
7
Rapid test
results in 20
minutes
Blood drawn
in ED for
confirmation
Tester
discloses
negative
results;
physician
discloses
positive
results
Referral to
guaranteed
HIV clinic drop-
in
appointment
Provider HIV

clinicians
and ED
clinicians
Yes Venipuncture
specimen
Targeted
to all
admitted
patients
and
symptoms/
risk factors
Verbal opt-
in by
physician;
implied
consent if
impacts
care
At the
discretion of
the
physician
Hospital
laboratory
24/7
Results
available in
electronic
medical

record in 1 to
2 hours
Confirmation
done on
same
specimen
Physician
discloses
negative
and positive
results
Dedicated HIV
clinic-based
linkage to care
team who will
meet patient at
disclosure
Provider
-Parallel
HIV
clinicians
and ED
clinicians
No Oral swab Non-
targeted
Verbal opt-
in by
triage
nurse
None Tester,

almost 24/
7
Blood drawn
in ED for
confirmation
Physicians
disclose
negative
and positive
results
Dedicated
linkage to care
liaison who will
meet patient at
disclosure
Christopou
los et al. Implementation Science 2011, 6:30
/>Page 4 of 9
expanding a pre-existing clinic linkage to care program
to the ED. Prior experience with a successful domestic
violence screening program within the ED also helped
shape the approach of the HIV testing program. As
explained by one of the ED physicians:
’So the first phase was to offer it, do some education,
see if we could link patients to care. See if the lab
could handle it, see if the physicians could handle it,
see if we were going to lose patients or not. So test
the system small It can be small and modest but it
needs to work. I don’t want to introduce a big, over-
whelmingly ambiti ous program that fails. And we

did the same thing with domestic violence.’
Providers were encouraged to test patients with
symptoms and signs of HIV infection. Program develo-
pers described rejecting a suggestion from potential
funders to co nsider changing their model o f testing, as
they believe d that targeted testing with an emphasis on
linkage to care was more important than screening
widely. One HIV clinic nurse described the rationale as
follows:
’ We were told we would like you to expand this
thing and go to what the model has been in other
EDs which is to do screening and hire test counsel-
lors and all that and we said no, that we didn’twant
to; that we really thought we were onto something
in terms of the model; that for us the critical priority
was-the reason w e were wanting to test people was
to link them into care and it wasn’ttotestthemfor
testing purposes to get the results.’
With CDC funding, the program expanded its testing
criteria to include all admitted patients and patients
with risk factors for HIV infection. This staff member
went on to emphasize the effort involved in successful
linkage to care:
’And the linkage to care piece is really, really inten-
sive; it’s not just appointment reminders and stuff
it’ s meeting people in the emergency department,
helping with disclosure, immediate test counselling,
post-disclosure counselling, partner notification,
some general education and then making the appro-
priate links here at the clinic end matching the

patient with an appropriate provider, ensuring the
transfer of medical information from their inpatient
stay and th eir diagnosis to the new medical provider
giving them rapid and easy access to the clinical ser-
vices. Also being available for the confirmatory test
for non-admitted patients so for patients who a re
seen in the ED and get their HIV test done there.’
The main barrier identified at this site was resistance
on the part of ED physicians t o offer what they viewed
as a test to be performed in a primary care setting. Pro-
gram implementers described how buy-in on the part of
ED physicians increased once they experienced how the
ability to di agnose HIV in the ED could directly impact
and improve the management of the patient’s presenting
ED complaint.
Site three: The provider-parallel model
At this site, the HIV clinic approached the ED about
obtaining CDC grant funding to implement a testing
program using site one as a model. ED staff were
receptive to this proposal because they felt their patient
population was similar in t erms of demographics to site
one and could benefit from this type of initiative. One
ED nurse recalled: ‘And I thought that this program
was an excellent program; something really good for
the community.’ In creating t heir program, staff at this
ED chose to adopt some, but not all, parts of the origi-
nal site one model. Similar to site one, triage nurses
offered patients the test. However, dedicated testers
were hired to carry out point of care testing and physi-
cians disclosed both negative and positive test re sults.

They also created a position for an HIV clinic-based
linkage to care staff person to act as a liaison between
the ED and the clinic. Similar to site two, this staff
member met patients in the ED at the time of diagno-
sis to help con duct confirmatory testing and provide
education and support. As at site one, this program
found that a key barrier to implementation was dis-
comfort on the part of some triage nurses with offering
patients the test. In addition, some nurses felt that cer-
tain HIV testing informational materials were too gra-
phic. The primary logistical barrier at this site was
ensuring that physicians remembered to give negative
test results to patients.
The common barrier to ED HIV testing: Concern about
disclosing a positive HIV result
Many of the att itudinal and logistical b arriers to HIV
testing in the ED were site-specific and depended on the
details of the p articular model of testing. Attitudinal
barriers included discomfort w ith offering the test, dis-
comfort with HIV informational materials, viewing HIV
testing as within the domain of primary care, and ‘pro-
filing’ patients as appropriate or not appropriate for an
HIV test. Logistical barriers included competing time
demands, lack of staff to offer and perform testing,
remembering to disclose negative test results, and qual-
ity control for point of care testing (Table 2). However,
across all models, ED physicians were responsible for
disclosing a positive HIV resu lt and program develope rs
described some concern and a nxiety on the part of ED
Christopoulos et al. Implementation Science 2011, 6:30

/>Page 5 of 9
physicians with regard to this disclosure. One HIV phy-
sician described the response of an ED physician:
’ Ican’ t tell somebody they have HIV. That’ stoo
devastating Yeah, I don’t have a problem telling a
family that their six-year-old was killed in a car acci-
dent.Icandothat.ButIcan’ t tell someone they
have HIV.’
One linkage to care staff member felt that this dis-
comfort was due in part to a stigmatized view of HIV:
’We’re convinced that one of the r easons that the
clinicians say we can’ t disclose a positive HIV test
result in the emergency department really comes
from stigma. Because they disclose bad news all the
time in emergency departments. You know, ‘Mrs.
Jones, we’ re really sorry to tell you your son was
shot and d ied,’ or, ‘Mrs. Jones, you’re 35-years-old
and you came in for back pain and guess what: you
have metastatic breast cancer.’’
This staff member observed that ED HIV testing
initiatives could play an important role in normalizing
perceptions of HIV among healthcare providers, not just
patients. To address concerns about disclosure, pro-
grams provided educational sessions about HIV along
with disclosure scripts and simple confirmatory testing
algorithms.
Common facilitators of HIV testing in the ED
Serving vulnerable urban populations
Program developers at all three sites framed HIV testing
as a way to improve care for underserved populations.

Many staff noted that individuals who were poor, unsta-
bly housed, o r from racial/ ethnic minorities often did
not typically access medical care elsewhere. One HIV
clinic nurse observed:
’ there are a lot of patients who don’tknowtheir
HIV status and many of them are patients that don’t
have primary care providers and o nly access
healthcare through the emergency depart ment and
urgent care. So it was, you know, an extension of
really trying to link marginalized populations who
don’t have access to HIV care, link them into care
and so it was sort of a natural, logical extension to
get into testing and put testing in the equation.’
An ED physician expressed a moral imperative to pro-
vide this service:
’The response was overwhelmingly supportive, like
this is absolut ely something we should d o. So t hey
were buying into it on this emotional civic duty. We
work at a county hospital. We owe it to our patients.
They have nowhere else to go.’
The secondary gain of re-engaging known HIV-infected
patients in care
Programs also alluded to the ‘secondary gain’ of being
able to connect HIV-infected patients who were not i n
care back into care. They observed that some patients
accepted the offer of testing without disclosing their
positive status and that this re-testing provided the
opportunity for re-entry into care.
’If they say ‘ IalreadyhaveHIV’ then I always tell
them make sure yo u ask ‘ Are they in care?’ [Be]

cause there are some that are not and they will give
them my card and I’ll contact them. Just a week ago
I had somebody who was in the ER for ETOH,
which is intoxicated. And he got tested; he didn’t tell
us that he was already positive. He’ sbeenpositive
for 15 years. When we were done the nurse would
go, ‘You know he’s HIV positive.’ I’mlike,‘No.’ So I
wentbackandtalkedtohimandIaskedhimhad
he ever gotten treated and he says, ‘ No.’ Isaid,‘In
15 years you’ ve never been treated and never been
to the doctor?’ And he said, ‘ No.’ So, he actually
came in the next day [be]cause I kept bugging him
throughout the course of the evening while he was
there. ‘You’re gonna come in tomorrow, right?’ He
actually got here at a quarter to eight in the morning
and he called me from the ER, I was still at home
Table 2 Barriers and facilitators to ED HIV testing
Site-Specific Barriers Common Barrier
’Profiling’ patients as appropriate or not appropriate for an HIV test Discomfort about disclosing a positive HIV test result
Discomfort about offering an HIV test
Discomfort about HIV informational materials
Viewing the HIV test as within the domain of primary care Common Facilitators
Competing time demands Serving vulnerable urban populations
Lack of staff to offer and perform the test The secondary gain of re-engaging known HIV-infected patients back into care
Quality control for point of care testing The support of the medical setting, e.g., social services, medical evaluation.
Remembering to disclose negative test results
Christopoulos et al. Implementation Science 2011, 6:30
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and he say s, ‘I’mhere.’ And I was shocked because
he was so intoxicated I didn ’t think he was gonna

remember but I said, ‘We have a lot of services, a lot
of d ifferent programs and we can help you.’ He
showed up. So I was racing to get here, and brought
himover,wefedhimandgothimtalkingtothe
social worker, you know, got him applied for Medi-
Cal and got him into a shelter.’
The support of the medical setting
Finally, many program developers perceived that offer-
ing HIV testing was one way to demonstrate to ED
patients they were receiving good medical care because
every person should know his or her HIV status to stay
healthy. They also viewed the medical environment as
a significant benefit when disclosing a positive result
because patients could feel that physicians were
invested in their diagnosis and in ensuring they
received the proper follow up care. One ED physician
stated:
’I think that as awkward as it is to get a diagnosis of
HIV this is the ultimate healthcare setting, right?
This place is crawling with doctors and w e’ ve got
specialists and you’re here and we’ re gonna help
you. And I think that as lonely as it might be getting
that diagnosis you’re also surrounded by - this is an
environment that just bleeds medicine, right? I
mean, I kind of think it’ s almost like an ideal
situation.’
A testing program coordinator at another site echoed
this sentiment:
’ Because if a person’ s get ting this diagnosis, it’ s
pretty daunting. You know, you came in for a bro-

ken leg and you find out you have HIV. That person
needs a bsolute support from all different directions
medically and probably in some cases people are
homeless or there are a lot of other issues around
that d iagnosis. And so what better way to support a
person than when they’re already there before you,
and you can, while they’re in the hospital, bring the
services to them. You can make sure that the person
has a ll the information they need about what it
means to be HIV positive, that it’snotadeathsen-
tence, it’sachronicillnesslikediabetes,thereare
things we can do to treat you.’
One tester pointed out that even though ED testing
programs may emphasize and facilitate follow-up care,
patients may perceive themselves as having other,
more important health priorities, and that respect-
ing patient autonomy was crucial, even if it meant
acknowledging that patients might not want to be in
HIV care:
’I believe the ED is where folks are coming for emer-
gency care and so I think that whatever they’re pre-
sentingwithiswhattheirissueisatthattime.I
think that HIV, even though it might be a v ery
important diagnosis to me and everybody else up in
there-you know what I mean-I think folks are still
wanting to come in to be serviced for what they
came in for, you know. And so I think that we
shouldneverforgetthatandthateventhoughit’s
very important to us the HIV clinic should be
another referral.’

Discussion
In this assessment of the development and implementa-
tion of HIV testing in three EDs, we found distinct
operational models - w hich we labelled the parallel
model, the provider model, and the provider-parallel
model - based on w ho offered and performed the test.
The adoption and evolution of each model was shaped
by local realities, including the relative contributions of
ED and HIV physicians in creating the testing program,
the criteria for patient s election, and the level of direct
obligation on behalf of the testing program with regard
to linkage to care. Similar to other studies that have
described provider concerns over the provision of fol-
low-up care [9,10], we found that the barrier to HIV
testing common to all sites was concern over disclosure
of a positive result. Our research also introduces several
important facilitators that have been mentioned little, if
at all, in the ED HIV testing literature: a commitment
to caring for underserved populations; the additional
yield of re-engaging known HIV-infected patients back
into care; and the power of the medical setting in pro-
viding immediate support for a newly diagnosed HIV
patient in the form of counselling, social services, and
medical evaluation.
With regard to the barrier of discomfort about dis-
closing a positive HIV test result, some program staff
felt that this concern arose in part from a stigmatized
view of HIV and that more widespread HIV tes ting in
the ED could help normalize perceptions of HIV among
ED staff. One of the stated goals of the 2006 CDC

guidelines was to reduce the stigma associated with HIV
testing [1], and our findings highlight that this process
has implications for healthcare providers as well as for
patients. Based on our f inding that the sites with exist-
ing programs were able to scale-up once ED staff devel-
oped a sense of famil iarity with HIV testing, it is clear
that comfort with the testing process is required before
screening efforts can be maximized. Indeed, one study
Christopoulos et al. Implementation Science 2011, 6:30
/>Page 7 of 9
showed that ED residents experienced an increase in
feelings of knowledge and confidence to conduct HIV
counselling and testing after a six-month period of test-
ing [10]. Thus , it may make sense for EDs interested in
implementing HIV testing to consider beginning with
pilot programs on a limited scale. Once a testing system
has been shown to be feasible and acceptable to patients
and providers, it can be refined and expanded. This con-
clusion is further supported by the fact all programs in
this study worked by tailoring their use of outside fund-
ing, i.e., ‘one size does not fit all.’
There were several limitations to our study. Our inter-
views were with ‘key informants’ whowereactiveparti-
cipants in efforts to monitor and improve program
outcomes. A wider sampling of ED staff not dir ectly
involved in program management would likely have
resulted in additional perspectives on barriers and facili-
tators of ED HIV testing. However, the stated purpose
of this evaluation was to chronicle the histories of these
programs while attending to barriers, facilitators, and

factors influencing the adoption of testing process ele-
ments, not to evaluate programs in their larger contexts.
This type of qualitative study would be an appropriat e
next step. We al so recognize that these sites were parti-
cipating in grant-funded projects, and thus may be more
likel y to champion the mission of ED HIV testi ng; how-
ever, we believe that the observations of this study are
still be of use to other urban EDs considering HIV test-
ing programs. In addition, as programs prefer to publish
data on the uptake and yield of testing themselves, we
do not provide information on the number of patients
tested or testing positive. Finally, these qualitative d ata
may not be generalizable across all ED HIV testing
programs.
Several areas merit attention in future research. As
emphasized in a 2009 Academic Emergency Medicine
Cons ensus Conference on ED HIV testing [11], it is not
clear how to sustain HIV testing in the ED in the
absence of external funding and how to determine the
optimal level of integration of HIV testing into ED activ-
ities. Further unders tanding the potential role of stigma
on behalf of ED providers with regard to testing may
help shed light on these important questions, since sus-
tainable and integrated ED HIV testing will necessarily
rely on attitudinal as well as financial support. Though
one study has reported on attitudinal changes among
ED residents before and after training and program
implementation [10], more studies are necessary. Based
on the variation in linkage to care practices among ED
HIV testing programs, and the variation in where the

responsibility for linkage to care lies, it is clear that we
need to understand more about the process of entering
care after an ED HIV diagnosis in order to optimize
mechanisms for linkage to care.
Conclusions
ED HIV testing ca n occur under a range of operational
models that em erge from institutional strengths and are
tailored to local realities. We identified three distinct
models of HIV testing that vary along the spectrum of
fully incorporating testing into the d uties of existing
staff to hiring additional staff to offer and perform the
test. For all models, incremental program development
maybeawaytopromotesustainabletestingefforts.
The combination of provider education and integrated
linkage to care may help mitigate barriers around disclo-
sure of a positive test result. Other staff feedba ck ses-
sions can help enhance the key facilit ators that em erged
from this study: belief in the social mission of ED HIV
testing, the perception that testing can connect out of
care HIV patients to care, and the availability of social
and medical resources in the ED to support pat ients
newly diagnosed with HIV.
Acknowledgements
Funding for this study was provided by the California Department of Public
Health, Office of AIDS, Contract 03-75344. This work was supported in part
by the National Institutes of Health 5P30MH062246 (PI: Morin), T32 AI60530
and K23 MH092220 (K.A.C), K23 MH079713 (S.W.), and K01 MH074369 (T.L.).
The authors would like to thank Kama Brockman at the California Office of
AIDS and the participants of this study.
Author details

1
San Francisco General Hospital HIV/AIDS Division, University of California
San Francisco, San Francisco, CA, USA.
2
Center for AIDS Prevention Studies,
University of California San Francisco, San Francisco, CA, USA.
Authors’ contributions
SW, TL, JM, and SM conceived the study and obtained research funding. KC,
KK, SW, and TL collected the data. KC, KK, and SW analyzed the data. KC
drafted the manuscript and all authors contributed substantially to its
revision. KC takes responsibility for the paper as a whole. All authors have
read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 15 October 2010 Accepted: 30 March 2011
Published: 30 March 2011
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doi:10.1186/1748-5908-6-30
Cite this article as: Christopoulos et al.: A comparative evaluation of the
process of developing and implementing an emergency department
HIV testing program. Implementation Science 2011 6:30.
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